Equitable access to high quality nursing home care for older and disabled populations is an important public policy issue given the aging and increasingly diverse U.S. population. Nursing home care has been described as a two-tiered system with the lower tier consisting of facilities housing predominantly Medicaid residents. These facilities are likely to have a higher proportion of minorities, and report lower quality car and operate in a resource constrained environment as their payer mix is predominantly Medicaid with lower reimbursement rates than Medicare and private pay. However, we observe performance variations across these resource-constrained facilities in both quality and financial performance. The proposed study will focus on the role of structural, market, and management factors in explaining quality and financial performance variations among nursing homes with high Medicaid census (>85%). Using a mixed methods approach, our study will address the following research aims: 1) Examine the structural and market factors associated with high performance among nursing homes with high Medicaid census. 2) Examine the association of management factors (leadership style, strategic orientation, HRM practices, and knowledge management) with high performance among nursing homes with high Medicaid census. 3) Examine whether nursing staff turnover mediates the relationship between management factors (leadership style and HRM practices) and performance among these nursing homes. 4) Explore how and why the factors tested in Specific Aims 1-3 may influence high performance from the perspectives of nursing staff and nursing home management. Our study is innovative in that it will be the first mixed methods study to explore contextual factors that may explain performance differences among facilities with high Medicaid census. This study will use a mixed methods, sequential explanatory design, consisting of two distinct phases, quantitative followed by qualitative. The quantitative analysis will use secondary data as well as survey data. The analytic sample for the survey will consist of managers from approximately 1000 nursing homes with high Medicaid census, and the qualitative sample will consist of interviews with nursing staff (6) and managers (2) from eight nursing homes (high and low performance) for a total of 64 interviews in 4 states (California, Georgia, New York, and Texas). The study findings will allow policymakers and nursing home managers to better understand the structural, market, and management factors associated with better performance in resource-constrained nursing facilities. We believe that the findings of our study and their dissemination will provide an impetus for developing interventions to improve the performance of these facilities in terms of lower costs and better quality. This may, in turn, reduce health care disparities for low income, minority, elderly, and disabled residents in these facilities, which are among AHRQ's priority populations.